Tag: supraclavicular lymph nodes

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the respiratory system.

Examination of the RESPIRATORY System Outline

1. looking out for sputum pots
2. examining the hands
3. examining the face
4. examining the neck
5. examining the chest wall

1. LOOKING OUT FOR SPUTUM POTS

• look around for sputum pots at the patient’s bedside
• if available, assess the quantity (large quantity may be a sign of bronchiestasis) and the character a.k.a. colour and consistency; haemoptysis (blood-streaked sputum) may be due to bronchial carcinoma, pneumonia, pulmonary infarction, bronchiestasis or tuberculosis; mucopurulent greenish-yellowish sputum may be due to a chest infection

2. EXAMINING THE HANDS

TAR STAINING

• check for tar staining of the patient’s fingers – this would indicate that the patient is a smoker

FINGER CLUBBING

• check for finger clubbing caused by interstitial oedema and dilation of the arterioles and capillaries
• assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
• advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
• finger clubbing causes may include cardiac issues such as cyanotic heart disease (heart disease that is caused by lack of oxygen) and infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart), respiratory issues such as bronchial carcinoma (a malignant cancerous tumour of the bronchi and the lung tissue), lung abscess (a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection), bronchiestasis (a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection), empyema (pus-filled pockets that develop in the pleural space), and fibrosing alveolitis (a disease involving the gas-exchanging portions of the lungs), and gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage)

PERIPHERAL CYANOSIS

• can be physiological eg. due to a surrounding cold environment, reduced cardiac output eg. shock causes central cyanosis
• featured through bluish discolouration of the nail beds
• usually starts showing when patient is at <85% SPO2

FLAPPING TREMOR

• ask patient to outstretch arms with the wrists in extension; in this position, the downward intermittent flap of the hands is exaggerated
• flapping tremor can be seen in patients with severe respiratory failure

HAND TEMPERATURE

• warm hands signify vasodilation or carbon dioxide retention
• cold hands signify vasoconstriction
• note if hands are dry or moist
• clammy hands may be a sign of anxiety or sympathetic activation

3. EXAMINING THE FACE

HORNER’S SYNDROME

• if Horner’s Syndrome is present, the patient may have unilateral constriction of the pupil (miosis), partial drooping of the eyelid (ptosis), impaired sweating on the same size of the face, and enophthalmos (recession of the globe in the orbital fossa)
• Horner’s Syndrome may be caused by an apical lung carcinoma infiltrating the sympathetic chain

PALLOR

CENTRAL CYANOSIS

• can be easily noted when looking at the patient’s tongue
• happens when the oxygen saturation of arterial blood falls below 80-85%; central cyanosis indicates lack of oxygen in the brain
• may be a sign of congenital heart disease (conditions present at birth which affect the structure of the heart and the way it works) or chronic obstructive airways disease or COPD

4. EXAMINING THE NECK

JUGULAR VENOUS PRESSURE (JVP)

• assessing the right internal jugular vein is better since it is more proximal to the superior vena cava than the left; the right external jugular vein has venous valves between it and the superior vena cava, hence it is less preferred for assessment; ideal patient placement is at 45 degree angle, looking to his left
• jugular venous pressure (JVP) can be noted as a double flicker above the clavicle parallel to the anterior border of the sternocleidomastoid muscle (remember that a venous pulse is never palpable)
• note the height by measuring the vertical height in cm between the top of the jugular venous pulsation and the sternal angle
• normal JVP height = <4cm
• high JVP height is a sign of increased pressure in the right atrium, and so, may be a sign of congestive heart failure, fluid overload (which may be due to nephrotic syndrome) or superior vena cava obstruction (non-palsatile)

CAROTID PULSE

• feel the carotid pulse – a bounding pulse indicates carbon dioxide retention

SUPRACLAVICULAR LYPMH NODES

• feel the patient’s supraclavicular lymph nodes
• if enlarged, they may indicate carcinoma, lymphoma, sarcoidosis or tuberculosis

TRACHEA

• feel the patient’s trachea; normally, the upper 4-5cm of the trachea can be felt between the cricoid cartilage and the suprasternal notch; compare distance to each side
• a displaced trachea may result from moving away from a lesion eg. due to a superior mediastinal mass such as lymphoma or carcinoma, massive pleural effusion, or retrosternal goitre, or moving towards a lesion eg. due to upper lobe collapse or fibrosis

5. EXAMINING THE CHEST WALL

CHEST SHAPE

• barrel chest is caused by an increase in the anteroposterior diameter relative to the lateral diameter of the chest wall. While the normal ratio is usually 5:7, patients with emphysema present with both measurements approximate; barrel chest may also be a sign of thoracic kyphosis (excessive curvature in the thoracic spine that leads to a rounded upper back)
• thoracic kyphoscoliosis – a patient with kyphosis presents with an excessive outward curvature of the spine, causing the back to hunch; a patient with scoliosis presents with lateral deviation of the backbone caused by congenital or acquired abnormalities of the vertebrae, muscles and nerves; a patient with kyphoscoliosis presents with abnormal curvature of the spine both forwards and sideways, in other words, a combination of both kyphosis and scoliosis
• pectus carinatum a.k.a. pigeon chest presents as localised prominence of the sternum and adjacent costal cartilages, commonly accompanied by indrawing of the ribs to form symmetrical horizontal grooves (Harrison’s sulci) above the usually everted costal margins; the deformities are thought to result from lung hyperinflation with repeated strong contractions of the diaphragm while the bony thorax is still in a pliable state; pectus carinatum is common following chronic respiratory disease in childhood eg. severe asthma
• pectus excavatum a.k.a. funnel chest is a developmental defect featuring either a localised depression of the lower end of the sternum, or depression of the whole length of the body of the sternum and of the costal cartilages attached to it; while this is usually asymptomatic, an increased degree of depression of the sternum may cause the heart to become displaced to the left, restricting the ventilatory capacity of the lungs
• iatrogenic chest is the result of former treatment for pulmonary tuberculosis with thoracoplasty, which involves surgical removal of parts of the ribs, allowing the chest wall to fall in and collapse the affected lung

SKIN

• look for scars from previous trauma, surgery, etc.
• look for evidence of radiotherapy eg. ink marks and telangiectasia (small, widened blood vessels on the skin, sometimes spidery in appearance, which blanche on pressure)
• look for subcutaneous nodules eg. metastases

RESPIRATORY MOVEMENTS

• rate of respiration is normally between 14-18 bpm; tachypnoea is noted in acute pulmonary infections (especially if accompanied by pleural pain), bronchial asthma, pulmonary embolism and acute pulmonary oedema
• mode of breathing – when breathing, women tend to use the intercostal muscles more than the diaphragm, with their respiratory movements being predominantly thoracic; men tend to rely more on the diaphragm, with their respiratory movements being predominantly abdominal; lack of chest expansion may be caused by ankylosing spondylitis (an inflammatory disease that over time can cause some vertebrae to fuse), intercostal paralysis (causes reduced vital capacity, inability to cough, and high mortality) or pleural pain; breathlessness is usually accompanied by respiratory distress, increased respiratory frequency and abnormal respiratory movements
• abnormal inspiratory movements – use of accessory muscles – sternomastoids, scaleni and trapezii, in-drawing of the suprasternal and supraclavicular fossae, intercostal spaces and epigastrium can be observed with each inspiration; paradoxical movements within the chest may indicate mobile fractures within the thoracic cage – these can cause serious issues such as respiratory distress and hypoxaemia due to interfering with pulmonary ventilation
• abnormal expiratory movements – commonly caused if the elastic recoil of the lungs are insufficient in completing air expansion from the alveoli, as in emphysema or asthma; patients exhibiting these symptoms tend to prefer leaning slightly forward in an attempt to augment their expiratory efforts, at times exhaling through pursed lips
• expansion of the chest wall – unilateral reduction of chest wall movement may be caused by pleural effusion, pneumothorax, lung consolidation (as in pneumonia, tuberculosis, neoplasm or infarction), lung collapse / lobectomy or pneumonectomy, and fibrosis (as seen in pulmonary tuberculosis); generalised restriction of chest wall movement may be seen in emphysema, bilateral pleural effusion, and ankylosing spondylitis (an inflammatory disease that over time can cause some vertebrae to fuse)

MEDIASTINAL DISPLACEMENT

• determine the position of the apex beat, which also reflects the position of the lower mediastinum; pleural effusion and pneumothorax may cause mediastinal displacement (pushed away); fibrosis, collapse, and pneumonectomy may cause mediastinal displacement (pulled towards)

TACTILE VOCAL FREMITUS

• tactile vocal fremitus is the palpable vibration transmitted through the bronchiopulmonary system to the chest wall when the patient makes a deep vocal sound
• fremitus is increased in consolidated areas within the lungs
• fremitus is decreased when the bronchus is obstructed or the pleural space is filled by fluid, air or solid tissue eg. pleural effusion, pneumothorax or fibrosis

PERCUSSION

• percussion is performed to compare the degree of resonance over equivalent areas on both sides of the chest, moving systematically from top to bottom

AUSCULTATION

• auscultate over each lung segment whilst patient breathes in and out gently through mouth
• note the character of the breath sound – diminished vesicular breath sounds may be caused by a generalised reduction in airflow eg. emphysema or tumour obstructing a bronchus, pleural effussion or pneumothorax; bronchial breath sounds in which both inspiration and expiration may sound as blowing in character, may be caused by consolidations, fibrosis or collapse
• listen for added sounds such as rhonchi (wheezes – generalised: due to asthma, chronic bronchitis, emphysema, pulmonary congestion caused by left ventricular failure; localised: due to local bronchial obstruction due to carcinoma, lymph node or foreign body), crepitations (crackles – fine crackles due to lung fibrosis, pulmonary oedema or pneumonia; coarse crackles due to chronic bronchitis or bronchiectasis), pleural friction rub (creaking sound due to pneumonia and pulmonary infarct), and pneumothorax click (rhythmical sound synchronous with cardiac systole)
• notice the character and intensity of vocal resonance – diminished vocal resonance is heard in pleural effusion, pneumothorax and collapse; increased vocal resonance is heard as a louder and clearer transmission of sound, commonly indicative of consolidation; in whispering pectoriloquy, the whisper is heard clearly with a stethoscope if there is consolidation, but is not heard if there is no consolidation; egophony is tested by asking the patient to say EEE aloud…if EEE sounds more like an A, consolidation may be present
• palpate for axillary lymphadenopathy which can be felt in patients with lymphoma and mestastases

Examination of the Respiratory System for Common Respiratory Problems

Disease	Mediastinal Shift	Tactile Vocal Fremitus / Vocal Resonance	Percussion Note	Auscultation
Consolidation	None	Increased	Dull	bronchial breath sounds, crackles, bronchosphony, egophony, whispered pectoriloquy
Chronic Bronchitis	None	Normal	Resonant	normal to decreased breath sounds, wheezes
Emphysema	None	Decreased	Hyper-Resonant	decreased intensity of breath sounds usually with prolonged expiration
Asthma	None	Normal to Decreased	Resonant to Hyper-Resonant	wheezes
Pleural Effusion	Away	Diminished	Stony Dull	decreased to absent breath sounds, bronchial breathing and bronchophony, egophony, whispering pectoriloquy above effusion over the area of compressed lung
Pneumothorax	Away	Diminished	Hyper-Resonant	absent breath sounds, possible click
Fibrosis	Towards	Diminished	Dull	late inspiratory fine crackles
Pulmonary Oedema	None	Normal	Resonant	crackles at the bases of the lungs, possible wheezes

Summary

Step-by-step examination of the respiratory system:

1. sputum sample examination – quantity & character
2. examine hands for flapping tremor, temperature, sweat, pallor, peripheral cyanosis, finger clubbing, nail swing, tar staining
3. check pulse
4. check respiration rate
5. check blood pressure
6. examine eyes for horner syndrome
7. observe face for signs of central cyanosis, pursed lip breathing, nose flaring
8. observe neck for JVP height, enlarged supraclavicular lymph nodes, trachea displacement
9. observe chest (lungs) for scars, evidence of radiotherapy, subcutaneous nodules, pectus excavatum, pectus carinatum, kyphosis, accessory muscle use for breathing
10. check for chest expansion, determine position of apex beat, and perform tactile vocal fremitus (ninety-nine – note character and intensity of vocal resonance)
11. percuss chest (lungs) over intercostal spaces and compare sides
12. auscultate chest (lungs) and check for bronchial sounds, wheezing, crackles, pleural friction rub, or pneumothorax click
13. repeat tactile vocal fremitus (ninety-nine – note character and intensity of vocal resonance), percussion and auscultation at the patient’s back
14. perform whispering pectoriloquy (whispering ninety-nine) if suspecting consolidation
15. assess under arms for enlarged lymph nodes in axilla

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